Publication Date


Document Type

Doctoral Dissertation

Academic Program

Clinical and Population Health Research


Quantitative Health Sciences

First Thesis Advisor

Sharina D. Person, PhD


Patient activation, cardiovascular disease, Acute Coronary Syndrome (ACS), self-management, chronic care


Background. AHA guidelines have been established to reduce Acute Coronary Syndrome (ACS)-related morbidity, mortality and recurrent events post-discharge. These recommendations emphasize the patient as an engaged member of the health care team in secondary prevention efforts. Patients with high levels of activation are more likely to perform activities that will promote their own health and are more likely to have their health care needs met. Despite evidence and strong expert consensus supporting patients as active collaborators in their own ACS care, the complexity and unexpected realities of self-managing one’s care at home are often underestimated. This study seeks to examine the correlates of patient activation at hospital discharge and then identifies activation trajectories in this same cohort in subsequent months. Lastly, this study examines the association between patient activation and health care utilization in the year subsequent to an ACS event.

Methods. This study incorporates three aims: Aim 1, identification of the correlates of low patient activation post-discharge; Aim 2, identification of patient activation trajectories among this same cohort in the months following hospitalization; and Aim 3, examination of the association between patient activation and health utilization, post-discharge.

Results. Fifty-nine percent of ACS patients identified as being at the lowest two activation stages at the time of hospital discharge. Perceived stress (pidentified post-discharge: low, stable (T1), high, sharp decline (T2), and sharp improvement (T3). The majority of patients (67%) identified as being in T1. Those patients of older age (OR: 2.22; CI 1.4- 3.5), identifying as Black in race (OR: 2.14: CI 1.1- 4.3), and reporting moderate/high perceived stress (OR: 2.54: CI 1.4- 4.5) had increased odds of being in the low, stable trajectory. The bivariate analysis indicated a significant association (P=0.008) between low patient activation and self-reported hospital readmissions in the months following discharge. In the final model, moderate to severe depression (OR: 1.60; CI 1.1- 2.3) was the strongest predictor of readmissions in the 12 months subsequent to discharge.

Conclusions: Patients reported low activation at hospital discharge after an ACS event indicated that these patients were not prepared to take an active role in their own care. Correlates of low activation at discharge include moderate to high perceived stress, depression, and low social support. Furthermore, in the months following hospital discharge, the majority of these patients followed either a low/stable or a sharp decline activation trajectory. Hence, these results suggest that over time patients feel less and less confident to take an active role in self-management. Lastly, we found that patient activation may impact healthcare utilization in the year subsequent to hospital discharge, although patient self-reported depression appears to be the strongest predictor of utilization in the subsequent year. Future research is needed to better understand the relationship(s) among patient activation, depression, and health care utilization.



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